A Guaiac-based faecal occult blood colorectal cancer screening program involving general practitioners is feasible and cost-effective for mass population screening



B. Denis
1, P. Perrin1, I. Gendre1, M. Ruetsch1, P. Strentz1, J. Y. Vogel1

1 ADECA 68, Association pour le Dépistage du Cancer Colorectal dans le Haut-Rhin, Colmar, France

Introduction        

Screening reduces both colorectal cancer (CRC) mortality and incidence but the best strategy for mass population screening remains debated.

Aims & Methods        

To report the results and cost of a population-based biennial faecal occult blood (FOBT) CRC screening program in the French area of Haut-Rhin (710 000 inhabitants), one of the highest CRC incidence areas in Europe. All 188,438 residents aged 50-74 years were invited by mail for a CRC screening using a non rehydrated FOBT (Hemoccult II). FOBTs were first provided by the GPs and then directly mailed to persons who didn’t comply after 2 invitations.

Results        

90,863 people (48.7%) completed a FOBT and 19,343 (10.4%) were excluded (high CRC risk or recent screening), so that adjusted participation rate was 54.3%. 77.3% of all completed FOBTs were provided by GPs and 15.5% were directly mailed. Participation ranged from 47.9% to 61.9% according to districts and was higher in women (56.6%) than in men (51.9%)(p<0.01). FOBT positivity rate was 3.3%. To date 2,595 colonoscopies were performed (84% of all positive FOBTs). Cecal intubation rate was 94.4%. Polyps were present in 45.2% of the colonoscopies and were adenomatous in 81.6% of cases. 1,746 adenomas were detected, 58.2% of them were sessile, 6.2% were flat, 4% were serrated and 26.5% had villous component. Their size was > = 20 mm in 16% of cases and from 10 to 19 mm in 26.1%. High grade dysplasia was present in 32.2% of adenomas, in situ carcinoma in 4.3% and invasive carcinoma in 2.2%. 95.2% of the adenomas were removed endoscopically. The positive predictive value was 10.3% for CRC, 21% for advanced adenomas and 42.6% for neoplasia (women 31.0%, men 52.2%). Detection rates for neoplasia and CRC were 12.2 and 2.9 per 1,000 people screened. 266 CRC were detected, 27.2% of them were in situ. 50% of invasive CRC were stage I and 23.4% stage II. The rate of proximal advanced neoplasia increased with age (16.5% below 65 years, 25.4% after) but didn’t differ with gender. A screening strategy with flexible sigmoidoscopy would have missed 21.4% of people with advanced neoplasia, without significant difference according to age and gender. The overall cost of this biennial screening program (without the fees related to colonoscopies) was €2.3 million: fixed cost was €1.6 million (4.3€ a year per eligible person) and variable cost €0.7 million (3.3€ per screened person). The overall cost per screened person was 26€ and the cost to find either an advanced adenoma or an early-stage CRC (in situ or stage I) was 3650€.

Conclusion        

Participation and diagnostic yield of controlled trials of guaiac-based FOBT screening are reproducible in the real world at an acceptable cost through an organized population-based program involving GPs.



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